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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 13 of 13 Results
Nasri B-N, Mitchell JD, Jackson C, et al. Surg Endosc. 2023;37:2316-2325.
Distractions in the operating room can contribute to errors. Based on survey responses from 160 healthcare workers, this study examined perceived distractions in the operating room. All participants ranked auditory distractions as the most distracting and visual distractions as the least distracting, but the top five distractors fell into the equipment and environmental categories – (excessive heat/cold, team member unavailability, poor ergonomics, equipment unavailability, and competitive demand for equipment). Phone calls/pagers/beepers were also cited as a common distractor. 
Jones TS, Black IH, Robinson TN, et al. Anesthesiology. 2019;130:492-501.
Surgical fires, though uncommon, can result in serious harm. This review highlights three components to be managed in the operating room to prevent fires: an oxidizer, an ignition source, and a fuel. The authors provide recommendations to ensure each element is handled safely.
Jones SB, Munro MG, Feldman LS, et al. Perm J. 2017;21:16-050.
Operating rooms are high-risk work environments. Improper use of energy-based surgical devices can increase risks of surgical fires. This commentary describes an initiative to address this safety concern by educating physicians and staff who work in the operating room environment about how to safely use the equipment. A past WebM&M commentary discussed operating room fires and how to prevent them.
Mentis HM, Chellali A, Manser K, et al. Surg Endosc. 2016;30:1713-24.
This systematic review found that equipment and procedural distractions were the most severe distraction events during surgery, but irrelevant conversation and movement were the most frequent. This underscores the need to reduce distractions and incorporate management of distractions into surgical education.
Fuchshuber PR, Robinson TN, Feldman LS, et al. Bull Am Coll Surg. 2014;99:18-27.
Surgical fires, though rare, can be particularly serious. This commentary analyzes factors that increase risks of these incidents, such as the presence of volatile substances in the operating room, use of highly-specialized technologies, and insufficient clinician experience with equipment.
Siracuse JJ, Benoit E, Burke J, et al. Jt Comm J Qual Patient Saf. 2014;40:126-133.
Written consent forms often introduce issues related to legibility and completeness. A Web-based system for booking elective surgical procedures improved the rate of obtaining and documenting informed consent in a community hospital system.
Arriaga AF, Gawande AA, Raemer D, et al. Ann Surg. 2014;259:403-10.
Simulation training for operating room (OR) teams is an effective tool for improving teamwork and communication, but can be resource intensive and expensive. Due to these barriers, most simulation programs have only included trainees. For this study, a malpractice insurer provided the financial and administrative resources necessary to develop a standardized OR simulation training curriculum that involved active participation of attending surgeons and anesthesiologists. The group provided modest compensation for physicians' time and achieved wide participation. This teamwork curriculum covered principles of communication, assertiveness, and use of the WHO surgical safety checklist. Nearly all (93%) participants thought that the training would help them provide safer care. Dr. David Gaba discussed simulation training in a recent AHRQ WebM&M interview.
Powers K, Rehrig ST, Schwaitzberg SD, et al. J Gastrointest Surg. 2009;13:994-1003.
This study compared the performance of surgeons younger and older than 55 in a simulated operative setting to demonstrate that age in itself is an arbitrary predictor of skill assessment. The authors advocate for simulation as a potential tool to evaluate performance in the context of re-credentialing.
Barrios L, Tsuda S, Derevianko A, et al. Surg Endosc. 2009;23:2535-42.
In this study of simulated cholecystectomies, surgical residents felt ill-trained to disclose both complications (common bile duct injury) and serious incidental findings (gallbladder cancer) encountered during a cholecystectomy. Most concerning, a large proportion of residents did not adequately describe potential complications when obtaining informed consent.